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The hot topic in Parkinson’s disease (Pd) management currently, is not so much what to treat with, but when to treat.

With Movement Disorders Section Chair, Peter Fletcher umpiring, this issue was debated at the Teva Pharmaceuticals and Lundbeck Sponsored Symposium “Timing of treatment in Parkinson’s disease” during the Spring Meeting at Bournemouth. Arguing ‘for’ was Richard Walker (North Tyneside) and ‘against’ was Chris Gordon (Winchester).

UK estimates suggest that around half of patients diagnosed with Pd are not started on medication immediately. This is often due to patient choice, but also due to the assumption that all treatments are purely symptomatic while most carry significant risks of side effects. Hence ‘against’ the motion, traditional teaching has been that it is better to wait until the patient suffers significant problems before initiating treatment.

However, ‘for’ the early treatment of PD are a number of studies (e.g. DATATOP, PDLIFE and the recent ADAGIO delayed-start study) which demonstrate that earlier treatment initiation offers benefits to patients both in terms of clinical progression of the disease and quality of life. It was also noted that there is a need to reappraise when changes are made to the patient’s medication, for example to manage wearing-off. There is a wealth of data to demonstrate the efficacy of adjunct therapy and now increasing moves to introduce adjunct therapy much earlier than before. We now have a better understanding of how to delay the use of levodopa and/or keep the dose low if initiating.

Not at issue, is that the choice of which medication class to use should be individualised. Effects on cognition (especially with dopamine agonists) and other side effects need to be taken into account.

So what of the debate? Well, Richard had a tough job as the audience’s pre-debate votes reflected the growing view that early treatment is indicated. Although Richard’s eloquence ensured that the post debate vote went his way, Chris’s forensic destruction of ‘the evidence’ did erode Richard’s margin somewhat!

My thanks go to both the speakers for their excellent contributions and to our sponsors for organising the session.

Peter Fletcher - Chair
BGS Movement Disorders Section

BGS Newsletter, March 2009
Issue 21 ISSN 1748-6343 21